Category Archives: Howard Gleckman

President Barack Obama wants to increase funding for a government program intended to make it easier for family caregivers to get respite care.

These hard-pressed families desperately need the helping hand. But the White House initiative is a symptom of all that is wrong with long-term-care policy in the U.S.

Government assistance for those who suffer from chronic illness is both terribly underfunded and deeply disorganized. There are programs run by Medicaid and Medicare and the federal Administration on Aging. There are programs run by states and similar projects run out of Washington. This is a particular nightmare for those with disabilities who are struggling to stay at home. If you don’t believe me, try to find a local phone number for elder care assistance.

I live in Montgomery County, Md., and a quick look at my phone book shows 18 different numbers for various senior services. If I need help that is not provided though the county, I need to call the state, which requires yet another frustrating search. Over the years, offices on aging and disabilities have tried to create one-stop shopping to make it easier to find help. And Maryland has a pretty good Web site that tries to pull together all these resources in one place. But the various programs go on for screen after screen. Imagine trying to navigate this if you are 75 years old and caring for a spouse with dementia.

The respite care program Obama wants to expand is typical of the problem. Respite care is temporary assistance for families who are helping the frail elderly or those with disabilities live at home. It may be a home health aide who visits for a few hours so a spouse can get a break. Or it may be an adult day program or transportation aimed at helping the person receiving care get out of the house.

The Lifespan Respite Care Act was passed by Congress in 2006. And its laudable goal was to encourage states to coordinate services aimed at giving family members a temporary break from their often stressful responsibilities. For instance, states could use the funds to make more information available to caregivers about respite services or to train care workers.

But the new law ran into two problems: Individual state agencies trying to protect their turf—and no money. For instance, the original law allowed up to $71 million for the program this year. But in its most recent budget, Congress agreed to make only $2.5 million available to states. The president now says he wants to increase this to about $50 million next year. At a time when the $1.4 trillion federal deficit is putting enormous pressure on spending programs like this, I’m willing to bet he’ll never get it all. And even if he does, he’d still only be spending a bit more than half of the $91 million the original law allowed.

For some sense of how little this is, think about it this way: By the administration’s own count, there are 38 million caregivers in the U.S. (others estimate there are many more). Even if Congress gave Obama the full $50 million, that works out to $1.31 per family. Of course, that’s a lot better than the six cents being spent today.

Worse, cash-strapped states are slashing their subsidies for the very adult day programs Lifespan is trying to promote. In a states such as California, for example, a federal program to promote these services won’t help much if the programs themselves are shuttered—an idea now being debated in Sacramento. And no small federal grant program will save them.

In today’s awful budget environment, financial pressure on government services for the elderly and others with disabilities will only get worse. The president has already proposed freezing overall spending for social programs exactly like Lifespan for the next three years. If more is spent on Lifespan, don’t be surprised to see funds cut for other badly needed assistance aimed at exactly the frail elderly and younger adults with disabilities.

At the same time, Medicaid—the primary long-term care support program for the sickest and poorest among us—faces its own budget crisis, both in Washington and in the states that pay about half its costs.

The best solution is to free families from the whims of politicians and the inevitable battles over government dollars. National long-term care insurance, such as the proposed CLASS Act, would help in two ways. First, it would give people cash benefits they could use however they want. They would not need to rely on underfunded and possibly inaccessible government programs. If a wife wanted to enroll her husband in an adult day program, she could just do it. Second, because millions of consumers would, for the first time, have the financial resources to pay for these services on their own, new private services would spring up that might do a better job than today’s diffuse and underfunded government programs. It is at least worth a try.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

The Washington Post recently ran a column arguing that the U.S. model for caring for the frail elderly and younger people with disabilities falls far short of the long-term care systems in France and the United Kingdom.

There is no doubt the U.S. scheme is deeply flawed. But even as Congress struggles to reform long-term services and supports here, France is wrestling with its own system.

And in Britain, long-term care is rapidly becoming a major political embarrassment for Labor Prime Minister Gordon Brown.

A bit of history: Two decades ago, most of the developed world relied on the same sort of welfare-based, Medicaid-type system that the U.S. still uses.

That is, if you were poor enough and sick enough, the state would provide some modest personal assistance.

If you were middle class, you were on your own—that is, until you spent so much on care that you became poor enough to qualify for government aid.

Most developed countries recognized this system was both needlessly cruel and fiscally unsustainable. The U.S. tried to keep people off Medicaid by encouraging them to buy private long-term care insurance. It tried tax subsidies, a government marketing campaign, and an effort to better coordinate private insurance with public benefits.

For the most part, it failed, and today, only about seven million Americans own private insurance.

At the same time, most of Europe and Japan went a different route. Building on their national health systems, they turned long-term care from welfare to social insurance.

Germany, for example, adopted a universal, national long-term care insurance system that aims to pay about half the cost of long-term care.

Japan took a similar, but slightly different, tack. In the face of massive pressure from women who were trying to hold down jobs while caring for their mothers and mothers-in-law, Japan also created a national long-term care insurance program.

Funded by both taxes and income-based premiums, Japanese insurance covers about 90 percent of the cost of care, though principally for those 65 and older.

France put its own spin on the social insurance model. It also provides universal tax-funded long-term care insurance, but benefits are closely tied to income. As a result, a very poor person might get the equivalent of $1,400-a-month for home care, while someone earning about $50,000-a-year might receive only a few hundred dollars.

As a result, in France, one-quarter of those 65 and older have purchased private long-term care insurance to supplement their government benefit.

While these changes are a big improvement over past practices, they have created their own problems. For instance, France and Japan, along with countries such as The Netherlands, have struggled with rapidly increasing costs and have had to reduce benefits. Germany has addressed its cost problem by raising the payroll tax that funds its insurance program.

Oddly, England, which The Post held out as a model of long-term care, may face the biggest mess of all. Unlike the rest of Europe, it has failed to reform its financing system in any significant way, and remains stuck in its failing welfare model.

While the elderly (and everyone else) get universal medical care through its National Health System, only the poor get government long-term care benefits.

And, because this assistance varies dramatically from one local jurisdiction to another, the system is widely disparaged as the “postcode lottery.”

The U.K. has struggled to fix this system for well over a decade. High-powered commissions have recommended major reforms, but little has been done. One scathing 2006 report by the Joseph Rowntree Foundation concluded “the public finds the present system incomprehensible and considers its outcomes unjust.” Not exactly a ringing endorsement.

Yet, reform efforts have gone nowhere. In July, Prime Minister Brown proposed a fundamental shift to an insurance-type model. But in November, he appeared to switch gears and call for expanding free care, but only for the most needy. For his troubles, Brown, who faces reelection this spring, is being roundly criticized by both conservatives and members of his own Labor Party.

There are two important lessons from the European experience. First, while an insurance-based system is vastly better than one that requires people to impoverish themselves before they can get help, it is not easy to implement. Second, the U.K is no model for reform.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Since the creation of Medicare and Medicaid nearly 45 years ago, the government has operated on the bizarre illusion that it can separate acute medical care from personal assistance and long-term care.

For real patients and their families, this makes no sense. Someone who is sick often needs both medical treatment and personal care. They should not have to worry about which is which.

But because this artificial wall defines government policy, it places many of the most vulnerable people in the nation at risk and very likely wastes billions of dollars.

An obscure provision of the Senate health bill attempts to at least crack that barrier. It would set up, for the first time, a government office charged with coordinating care for more than eight million “dual eligibles,” the poorest and sickest among us who receive both Medicare and Medicaid benefits.

Organizing this care is especially important for the frail elderly, who often suffer from multiple chronic diseases, take a dozen or more medications, and may see 10 different doctors. And it matters to taxpayers who spend $200 billion per year caring for these patients.

To understand the problem, think about a 75-year-old I’ll call Fred. At 2:00 one morning, Fred wakes up with severe chest pains and breathing problems. He calls 911, and the EMTs transport him to the local hospital. There, he undergoes aggressive life-saving treatment, perhaps including major heart surgery, much of which is paid for by Medicare.

But it turns out that Fred’s heart attack caused serious damage to his heart muscle. As a result, it can no longer pump blood through his system as efficiently as it should.

This disease, called congestive heart failure, is among the most common chronic illnesses of the elderly. CHF can be managed for many years with a combination of medications and other treatments, but it can be severely debilitating.

In time, as the damaged heart becomes steadily weaker, getting out of bed, walking, eating, and making decisions become harder.

Still, someone with CHF, as well as those with many other chronic illnesses, can be cared for at home. But that requires a trained aide or willing family member. If there is no one to provide this help, patients such as Fred will almost surely wind up in a nursing home or receiving a high level of care in an assisted living facility.

Now, let’s make the story a little more complicated. Although Fred worked hard for most of his life, his heart disease has drained all of his financial resources and he receives both Medicare benefits and assistance through Medicaid, the joint state and federal health program for the poor.

Medicaid was originally designed to provide health care for low-income mothers and their kids, but now spends two-thirds of its dollars on the aged and disabled.

But, with the exception of a handful of limited programs, Medicare and Medicaid do not coordinate their care. So Medicare will pay for most of the cost of Fred’s hospitalizations and for his medications, but – except for a limited period of time – not for the health aide he needs to stay at home.

That is Medicaid’s responsibility.

The consequences of this are both potentially deadly for Fred and costly for the rest of us. Fred needs someone to help manage his meds, and help dress and feed him. He also needs someone to get him on a scale every day or two. That’s because weight gain is a sure sign that his heart is not pumping well. With proper warning, his doctors can get Fred back on track by simply adjusting his medications. But if this signal goes unnoticed, he’ll almost surely end up back in the emergency room.

And here is where this strange story takes its final twist. The aide who could help Fred avoid a medical crisis simply by weighing him is paid by Medicaid. But if she helps keep him out of the hospital, the biggest beneficiary is likely to be Medicare.

Not surprisingly, cash-strapped states are not happy about having to pay for aides who reduce costs for the feds.

There are a few models out there that hold great promise for what could be. For instance, the Program for All-Inclusive Care for the Elderly (PACE) provides both adult day care and high quality medical treatment for these dual eligibles—and it is jointly funded by both Medicare and Medicaid. The two programs ought to find new ways to build on that model. And they could start by talking to one another.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

This column was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

In the ongoing congressional debate over the CLASS Act—the proposed national long-term care insurance program—critics and supporters have been arguing over whether a benefit of $50- or even $75-a-day is worthwhile.

Some in the insurance industry, for instance, assert that given the high cost of care in nursing facilities and even at home, a $75 benefit is hardly worth the premium cost.

But an important new study tells a different story. Caregiving in the U.S. is a data-rich profile of family caregivers—the third such survey in the past 12 years. And it paints a picture of families for whom $75-a-day could make a real difference.

The study, by the National Alliance for Caregiving and AARP and funded by the MetLife Foundation, estimates that about 48 million people are caring for the frail elderly or younger adults with disabilities. Another 17 million are assisting children with special needs. Together, that’s more than a fifth of all Americans.

But for now, let’s just focus on those caring for people 50 and older. Keep this picture in your mind: A 50-year old woman who is married and trying to hold down a job. The chances are about one in three that she is also raising a child. Typically, she is helping her mother, a 77-year-old widow who is either living in her own home or with her caregiver daughter.

The survey found only about six percent of those being cared for are in nursing homes. Three-quarters need care due to a long-term physical disability and nearly one of six is suffering from dementia or “confusion.”

This daughter has been caring for her mom for an average of four years, and she is spending about 20 hours a week helping with grocery shopping, rides to the doctor, housework, making meals, or more intensive assistance such as helping her mother get up from her bed or chair. About one in three caregivers are helping their loved one get dressed or to the bathroom. Among those who work, nearly two-thirds take time off during the workday, 17 percent take a formal leave of absence from their jobs, and 10 percent quit or take early retirement.

These caregivers are spending a bit less time helping than in 2004. The reason: They are getting help. About 70 percent receive assistance from other relatives or friends, up five percentage points. And about 40 percent are relying on paid help from, for instance, home health aides. But that’s down from 45 percent five years ago. Why? The cost, most likely.

The biggest burden of all, however, is on elderly spouses. They spend more than 30 hours a week caring for loved ones. They are more likely to be doing the difficult work of assisting with activities such as bathing. Yet, they are often doing this on their own, without help from relatives or friends.

And that’s where even a $50 cash benefit can make all the difference. That money would pay for nearly three hours-a-day of a home health aide’s time, and even more if the dollars were used to pay a relative or friend.

For a daughter trying to juggle caregiving and work, that could make the difference between having to scale back hours or even quitting her job, and being able to stay in the workforce. And remember, the work hours she gives up today mean she is paying fewer taxes, accruing fewer Social Security benefits and putting less aside in her own 401(k) retirement plan.

For a beleaguered spouse, having the money to pay for help can mean critically-needed respite care, or assistance getting her frail husband washed and dressed each morning.

No doubt, compared to the more than $200-a-day people pay for care in a skilled nursing facility or the cost of 24-hour home care, $50 or $75 isn’t much. For many, it would only delay by a few months the time when they would go on to Medicaid.

And those with higher incomes who worry about needing very costly care would almost surely buy private insurance to supplement any government coverage. But most of those caring for parents or spouses are providing help at home. And for them, three or fours hours of assistance can make all the difference.

When it comes to the CLASS Act, there is plenty to fight about. But I’ve met an awful lot of families whose lives would be made profoundly better by that $75-a-day. Caregiving in the U.S. tells us there are millions more like them.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

‘Aging in Place’ is the popular rallying cry in the senior community. But living at home is not so easy, either for the frail elderly or younger people with disabilities.

Interestingly enough, the reasons may have more to do with social issues than medical concerns. Today, almost everyone could receive the care they need at home, even if they suffer from multiple chronic illnesses. But the frail elderly still move to assisted living facilities or nursing homes.

For many, that transition is driven by a lack of qualified caregivers, an absence of basic services such as transportation, no access to appropriate housing, and loneliness.

Let’s look at these problems one at a time.

Caregivers: Nearly two-thirds of those being cared for at home receive all of their assistance from family members and friends. But these informal caregivers are untrained, and face huge physical, emotional and financial burdens. And they burn out.

In Japan in the 1990s, it was called ‘caregiver hell’ and the backlash drove profound changes in the way that nation financed elder care. We prefer to imagine family caregiving as a gauzy Sunday night movie where families rebuild fractured relationships before mom dies in peace. But, in truth, things rarely turn out that way. Caregiving is hard.

A new study by The Urban Institute’s Brenda Spillman and Sharon Long finds a major link between caregiver stress and a patient’s move to a nursing home. The biggest cause: physical strain. But financial hardship and an inability to sleep play a big role as well.

Spouses of the frail elderly may suffer the most, since many face their own physical or cognitive limitations. But adult children are hardly immune, especially those who must balance jobs and kids with caring for parents. Long-distance caregivers face particular challenges. And many of the very old may have outlived both spouses and children, and now have no one to care for them.

Home health aides are a solution for some. But quality care workers are not easy to find. It is no wonder: they earn an average of less than $10-an-hour, rarely receive benefits such as health insurance and are more likely to be injured on the job than coal miners. There are many capable and loving aides out there. But there is far more demand for help than they can fill.

Lack of Services: The most important may be transportation. Something as simple as a reliable ride to the supermarket or the doctor may be the difference between staying at home and having to move. Yet, many communities are scaling back transit programs for the elderly and disabled in the face of budget problems.

Housing: You can’t live at home if you don’t have a house. And finding one is a challenge for the many seniors and disabled with low-incomes. Even if you do have a home, it may need to be renovated to accommodate a wheelchair or a walker, and that can cost more money than many seniors have. And few government programs will help. Medicaid will pay for nursing home care, and will provide limited benefits for home care. But, with rare exceptions, it doesn’t do housing.

Loneliness: Staying at home can be extremely isolating, especially for a widow or widower. Adult children may provide practical assistance, but they have their own lives and often can’t be there for simple companionship. Old friends may find it difficult to visit as they struggle with their own physical decline. For all their limitations, nursing homes and assisted living facilities at least provide activities and companionship.

There are solutions. Better training is critical for both family caregivers and paid aides, who also deserve higher pay and better benefits. Respite care, including adult day centers, gives caregivers a desperately needed break. Community-based programs can match up volunteers with those who need rides or friendly visits.

All of this costs money. We can fund some of it through a more flexible Medicaid program. But a better solution is broad-based long-term care insurance that would give families the financial resources they need to provide appropriate care to their loved ones.

We’ll never keep everyone at home. Assisted living and nursing home care may still be necessary for those with no families or those suffering from severe dementia. But if we work at it, we can postpone the transition for months or even years. It is worth trying.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

Baby Boomers are tragically unprepared for financing their health and long-term care costs as they age. And some important new studies show their circumstances may be much worse in the wake of recent carnage in both the economy and financial markets.

One study by the Employee Benefit Research Institute shows that in 2008, the average 401(k) balance of 50-somethings was just $113,000, and for those in their 60s it was barely $125,000. These 401(k) plans and Social Security represent the vast bulk of most Americans’ financial nest eggs in retirement.

But even these grim statistics mask the depth of the problem for many. Only one out of every six of those in their 60s have 401(k) assets of more than $100,000. Many have less than $50,000.

Housing, of course, is the other major asset retirees can use to help pay for medical or long-term care costs. But many Boomers borrowed heavily against their home equity during the housing bubble, then suffered a big decline in their home values during the bust. The combination, according to the Center for Retirement Research at Boston College means that many of those entering retirement lost as much of a third of the equity they had in their homes at the peak of the market.

The Boomers potentially have one other resource to get them through health and long-term care crises in old age—insurance. But the news there is also bad. Retiree health coverage, once a mainstay for the aging, is fast disappearing. According to a new report by the Kaiser Family Foundation and the Health Research and Educational Trust, just 29 percent of employers even offered retiree health benefits to their workers in 2008. That was just a fraction of the nearly two-thirds of companies that provided this coverage 20 years ago.

That leaves Medicare, which faces an untenable financial future. Medicare premiums, especially for high-income retirees, will skyrocket in coming years without significant efforts to contain costs. As I noted in a recent column, many can expect to pay as much as $5,000 a year in combined premiums for Medicare Part B and Medicare Supplemental (Medigap) within a decade.

In yet one more study, EBRI looked at a 65-year-old whose former employer does not subsidize his retiree health insurance. A man in that situation will need $186,000 in savings in order to have just a 50 percent chance of paying his medical costs a decade from now. A woman must have $266,000.

Then, there are long-term care expenses. The annual cost of a nursing home stay is nearly $80,000 and can easily be more. The average cost of a home health aide is nearly $20 per hour. A typical senior will need to put aside nearly $50,000 to fund long-term care, and some will need far more. About 20 percent are expected to require care for five years or more.

However, only seven million Americans have private long-term care insurance and few show any interest in buying the product as currently designed. They will have to turn to yet another government program, welfare-like Medicaid. Yet it too faces immense financial pressures. The Congressional Budget Office estimates that, by mid-century, the federal share of Medicaid will absorb more than 16 cents of every tax dollar. States, which pay half the program’s costs, will face a similar burden.

To review the bidding, remember the average 401(k) balance for those in their 60s at the end of last year was $125,000. But they’ll need well over $200,000 in savings just to pay their medical bills.

And, of course, health care is just a fraction of a retiree’s living expenses. Where will the money come from for transportation, food, rent, utilities, and taxes? Try to pay all those bills on a Social Security check that averages about $1,200 a month.

The only good news in these studies is that they looked at the nest eggs of near-retirees at the end of 2008—which was close to the bottom of the collapse in stock prices. The market has already recovered some of those losses and, over the years, may recover more.

Yet the basic story will remain the same. We are not ready for healthy retirement, and we are desperately unprepared for the costly medical and long-term care we are likely to need in old age.

Taken together, these studies should be a wake-up call. They scream for change—in the way we save, in the Medicare and Medicaid programs, and in the way we finance long-term care.

Howard Gleckman, a senior research associate at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

Elders often tell their adult kids to shoot them rather than send them off to the nursing home. We may not be disposing of our parents, but we are killing the nursing homes, at least as we know them. In not too many years, long-term care nursing home beds may be as rare as Republicans in Massachusetts.

Many may cheer at this news. But the need for the intensive level of care provided by skilled nursing facilities isn’t going away. As hospitals discharge patients “quicker and sicker,” many need a level of assistance they cannot receive at home. As medical technology keeps people with horrific injuries and severe illness alive for years, they will need careful monitoring and drug treatments that are beyond the abilities of most family caregivers or part-time paid aides. So where will they get this care?

The trend away from nursing homes is already clear. The number of facilities has fallen by nearly 1,000 to about 15,700 since 2000. More than 80,000 beds have been shuttered over those nine years. And the number of Medicaid-only beds—those certified for long-term care stays– has plunged by half since 1995, to about 114,000.

All this is happening even as the population of those 75 and older—those most likely to need long-term services—has grown from 16.6 million to almost 19 million/

Why the change? In part, it is because Medicaid is gradually providing more long-term care at home, although the pace of change remains slow.

Another reason is simple economics. Medicaid payments to nursing homes are very low—averaging only about $125 a day, although they vary widely from state to state. And facility operators say they lose money on every Medicaid resident. Some non-profits manage by tapping endowments or gifts. But for-profits, especially those being run by private equity firms or other investors, won’t continue this business model for long.

Those who pay out of their own pockets are charged much more–an average of over $200-a-day—but they represent just a small fraction of nursing home residents.

While Medicaid underpays for long-term care patients, Medicare pays much more generously for rehabilitation after a hospital stay. Rates vary widely, but facilities can easily get $400 or $500 per day for such care.

While nursing home long-term care is being squeezed, seniors and their families are turning to alternatives such as assisted living. Two decades ago, there were just a few thousand of these facilities. Now there are more than 20,000, with more than 1 million beds. In Minnesota, for instance, the number of nursing home beds has dropped from more than 50,000 to 35,000 in just a few years. But most of those would have been in skilled nursing are now in assisted living, not their old homes.

Many facilities are operated by the same firms that run—or used to run—stand-alone nursing homes. The new mantra in the industry is continuum of care: home health, independent living, assisted care and skilled nursing.

The shift to assisted living is, on the whole, a good thing. These facilities can provide good care in a more comfortable setting at roughly half the cost of skilled nursing. Yet this shift is not without problems. Just as nursing homes residents are sicker than ever, so too are assisted living residents. According to one industry survey, more than a third suffer from dementia, and the typical resident takes an average of nine medications a day.

Although residents look increasingly like the nursing home patients of a few years ago, regulation of these facilities has changed slowly and varies widely from state to state. There is not even a common definition of assisted living, which can range from large corporate-owned residential complexes to small board-and-care homes that house one or two elderly lodgers.

Some states require facilities to meet complex licensing requirements, others are far more lax. Some require extensive dementia care training, others none at all. While the federal government closely monitors nursing homes, supervision of assisted living facilities is largely left to the states.

While this lack of intense regulation gives facilities flexibility to provide more home-like care, it also poses obvious health, safety and financial risks to patients—especially those who need complex care.

Senior living facilities have been battered by the recession. With the average nursing home more than three decades old, expect a wave of both consolidation and new construction when the economy eventually turns around.

But that will mean even fewer long-term care beds. And as the role of nursing homes shrinks, we’ll all need to pay far more attention to the alternatives.

Howard Gleckman, a senior research associate at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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